Renal function after low central venous pressure-assisted liver resection: assessment of 2116 cases.

OBJECTIVES: Low central venous pressure (LCVP)-assisted hepatectomy is associated with decreased blood loss and lower transfusion rates. Concerns about its impact on renal function have prevented widespread application. This study was conducted to review the dynamics of renal function after LCVP-assisted hepatectomy. METHODS: A retrospective analysis of a prospective surgical database was carried out. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation. The RIFLE (risk-injury-failure-loss-end-stage) criteria were used to define postoperative biochemical acute kidney injury (bAKI). Occurrences of clinically relevant AKI (cAKI) were identified in the study center postoperative database. RESULTS: During the period 2003-2012, 2116 LCVP-assisted hepatectomies were performed. The median patient age was 61 years [interquartile range (IQR): 51-70 years] and 51% of patients were male. The median number of resected segments was two; resections involved from one to four segments. Median estimated blood loss was 300 ml (IQR: 200-600 ml). Rates of morbidity and 90-day mortality were 21% and 2%, respectively. Low baseline eGFR (<90 ml/min) was seen in 84% of patients; 29% of patients had eGFR of <30 ml/min. Postoperative bAKI was seen in 17% (n = 350) of patients. Biochemical AKI with low eGFR was seen in 336 patients, representing 16% of the whole cohort; 13% of patients had been at risk, 2% experienced injury and 1% experienced failure. Kidney function had normalized at discharge in 159 of these patients. Nine patients (<1%) developed postoperative cAKI. CONCLUSIONS: The majority of patients in the study cohort had low baseline eGFR. Biochemical alterations in eGFR are transient in the vast majority of patients after LCVP-assisted hepatectomy and their clinical impact is limited. The present data suggest that clinically relevant renal dysfunction is a very uncommon event in patients undergoing LCVP-assisted liver resection.

Goal-Directed Fluid Therapy Using Stroke Volume Variation for Resuscitation after Low Central Venous Pressure-Assisted Liver Resection: A Randomized Clinical Trial.

BACKGROUND: The optimal perioperative fluid resuscitation strategy for liver resections remains undefined. Goal-directed therapy (GDT) embodies a number of physiologic strategies to achieve an ideal fluid balance and avoid the consequences of over- or under-resuscitation. STUDY DESIGN: In a prospective randomized trial, patients undergoing liver resection were randomized to GDT using stroke volume variation as an end point or to standard perioperative resuscitation. Primary outcomes measure was 30-day morbidity. RESULTS: Between 2012 and 2014, one hundred and thirty-five patients were randomized (GDT: n = 69; standard perioperative resuscitation: n = 66). Median age was 57 years and 56% were male. Metastatic disease comprised 81% of patients. Overall (35% GDT vs 36% standard perioperative resuscitation; p = 0.86) and grade 3 morbidity (28% GDT vs 18% standard perioperative resuscitation; p = 0.22) were equivalent. Patients in the GDT arm received less intraoperative fluid (mean 2.0 L GDT vs 2.9 L standard perioperative resuscitation; p < 0.001). Perioperative transfusions were required in 4% (6% GDT vs 2% standard perioperative resuscitation; p = 0.37) and boluses in the postanesthesia care unit were administered to 24% (29% GDT vs 20% standard perioperative resuscitation; p = 0.23). Mortality rate was 1% (2 of 135 patients; both in GDT). On multivariable analysis, male sex, age, combined procedures, higher intraoperative fluid volume, and fluid boluses in the postanesthesia care unit were associated with higher 30-day morbidity. CONCLUSIONS: Stroke volume variation-guided GDT is safe in patients undergoing liver resection and led to less intraoperative fluid. Although the incidence of postoperative complications was similar in both arms, lower intraoperative resuscitation volume was independently associated with decreased postoperative morbidity in the entire cohort. Future studies should target extensive resections and identify patients receiving large resuscitation volumes, as this population is more likely to benefit from this technique.